Sales Rep / Chemical Area Manager Contact Information
Sales Representative Name:
Sales Representative Phone:
Sales Representative Email:
Global Chemical Area Manager Name:
Account Information
Company Account Name:
Customer Contact Name:
*
Account Number:
Address:
*
City:
*
State/Province:
*
ZIP/Postal Code:
*
Phone:
*
E-mail:
*
Product Information - For All Inquires
Catalog Number :
If no catalog number is available, please provide chemical name / CAS number, and Grade
CAS Number :
Chemical Name :
Grade :
Specify documentation and controls required if needed :
TPP (Third Party Procurement) :
TPP signifies no labeling, testing or packaging by Fisher.
Yes
No
Market Segments - required for all non-catalog requests
Please select one of the following:
Select one
Research Use Only
Industrial
Pharma/Biotech
Active Pharmaceutical Ingredient
Others
Application, if known:
How many units should we quote on? (i.e. 5, 10, 100, multiple volumes)
Package Size and Unit: (i.e. 50 KG, 4 Liter)
Annual Usage:
Should we quote on the annual usage?
Yes
No
Has the customer performed any pre-evaluation or sampling of our Global Chemicals material?
Yes
No
If Yes – please provide part number and lot number
Current Supplier:
Current/Target Price:
Additional Information - For Specialized Services Only
Testing Requirements :
(or you may attach as a separate attachment)
Custom Blend Requirements W/W, V/V, W/V, and Tolerance Range for each component :
Component 1
Component 2
Component 3
Any Relevant Additional Information :
(or you may attach as a separate attachment)
Do you need to know the number of pallets that will be used for Deduct and Hold (D&H)?
Yes
No
Fisherpak Requirements
FisherPak™ :
19
50
200
Tote (stainless steel): 1350li
Other Size:
NowPak2 (steel outer drum):
19L size only
Required number of drums/totes
@ customer (at 1 time):
Number of dispensing points :
Is additional Fisherpak Hardware needed :
for example:("Autovalve")
SOP-8000 (A) - Attachment 1 SCS Quotes Request Form